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Memorandutn  on  the  Ideal  Development 
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Digitized  by  the  Internet  Arcinive 

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Open  Knowledge  Commons 


http://www.archive.org/details/memorandumonidea01lamb 


MEMORANDUM 


ON 


THE   IDEAL  DEVELOPMENT 


OF 


HOSPITAL  AND  MEDICAL  SCHOOL 


Addressed  to  the  Trustees  of  Columbia  University 
and  the  Managers  of  the  Presbyterian  Hospital 

BY 

SAMUEL  W.  LAMBERT,  M.D. 

Dean  of  the  College  of  Physicians  and  Surgeons 

Columbia  University 


PRINTED  FOR  PRIVATE  DISTRIBUTION 
NEW  YORK,  MARCH,  1912 


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To  the  Board  of  Trustees  of  Columbia  University  and  the 
Board  of  Managers  of  the  Presbyterian  Hospital, 

Gentlemen : 

Some  years  ago  I  prepared  a  study  of  the  relations  be- 
tween hospitals  and  medical  education  in  order  that  the 
subject  might  be  presented  to  the  Committees  of  the  Roose- 
velt Hospital  and  of  Columbia  University  who  were  con- 
sidering at  that  time  the  possibility  of  a  closer  relationship 
between  those  two  institutions.  That  negotiation  failed  to 
accomplish  any  result  whatever,  but  an  alliance  between 
Columbia  and  the  Presbyterian  Hospital  has  been  entered 
into  for  the  same  purposes  as  then  contemplated  and  the 
following  study  of  the  same  subject;  hospitals  and  medical 
education  has  been  made  with  the  hope  that  it  might  assist 
in  formulating  plans  for  the  future  development  of  both 
the  Presbyterian  Hospital  and  the  College  of  Physicians 
and  Surgeons  under  that  argeement. 

The  opinions  expressed  in  the  following  pages  are  en- 
tirely my  personal  views.  They  represent,  so  far  as  I  know, 
in  no  sense  the  ideas  either  of  any  other  member  of  the 
medical  faculty  or  of  the  executive  officers  of  the  Uni- 
versity. Nor  have  I  consulted  in  preparing  this  paper  the 
opinions  of  the  members  of  the  Medical  Board  or  of  the 
Board  of  Managers  of  the  hospital.  It  seems  to  me  that  a 
full  discussion  of  the  problems  now  before  the  University 
and  the  hospitals  should  be  had  at  the  present  time  in  order 
that  this  alliance  may  result  in  as  perfect  an  institution  for 
medical  teaching  and  research  as  can  possibly  be  brought 
about.  In  order  that  this  end  may  be  furthered  I  have 
had  these  pages  printed  and  distributed  to  the  members 
of  your  boards. 

This  alliance  for  the  advancement  of  medical  education 
and  medical  science  between  the  Presbyterian  Hospital  and 
Columbia  University  finds  both  institutions  in  an  enviable 
condition.     Both  the  hospital  and  the  medical  department 


of  the  University  are  occupying  buildings  which  they  have 
outgrown  and  which  they  are  anxious  to  replace  with 
modern  plants  and  as  far  as  possible  with  model  institu- 
tions. Before  this  alliance  was  consummated  Columbia 
University  was  endeavoring  to  secure  a  site  for  the  re- 
building of  the  College  of  Physicians  and  Surgeons  in  116th 
Street  near  the  rest  of  the  University  and  the  Presbyterian 
Hospital  had  purchased  a  site  at  67th  Street  and  East 
River  on  which  to  build  a  new  hospital.  The  purpose  of 
this  pamphlet  is  to  discuss  the  many  questions  which  arise 
as  a  result  of  this  Hospital-University  alliance. 

The  first  question  to  come  to  one's  mind  is  that  raised 
by  this  very  fact  that  both  these  institutions  had  already 
considered  the  advisability  of  building  new  quarters  in 
different  parts  of  the  city.  The  one  preeminent  idea  which 
has  never  varied  in  the  conclusions  of  all  who  have  con- 
sidered this  alliance  is  that  the  new  hospital  and  the  new 
school  must  be  built  in  close  physical  relationship  one  to 
the  other.  This  fact  seems  self-evident  and  no  argument  in 
favor  of  a  divided  school  and  hospital  has  been  even  sug- 
gested which  seems  worthy  of  refutation.  This  question 
of  propinquity  is  therefore  not  touched  upon  now,  but  is 
assumed  as  settled.  Another  question  which  is  even  more 
important  is  that  of  the  financial  means  of  carrying  out 
these  projects.  This  also  is  not  discussed  at  this  time, 
but  an  attempt  will  be  made  to  draw  up  a  scheme  for  an 
ideal  institution  combining  a  medical  school  and  hospital  so 
far  as  such  an  institution  can  be  outlined  under  the  condi- 
tions imposed  by  a  site  in  a  large  city  in  general  and  in 
New  York  in  particular  and  any  scheme  of  financing  the 
plans  which  may  be  finally  adopted  is  left  for  future  and 
more  confidential  discussion. 

The  essential  characteristics  of  a  site  for  a  hospital  are 
a  southern  exposure  insuring  an  excess  of  sunlight  and 
fresh  air  for  its  wards,  its  flat  roofs  and  balconies.  A  school 
of  medicine  should  demand  from  its  site  a  northern  expo- 
sure to  secure  clear  steady  light  for  its  laboratories  and 
scientific  workrooms.  The  administrative  and  secondary 
workrooms  in  both  hospital  and  school  and  the  accommo- 


dations  for  students  in  the  school  can  be  fitted  in  to  the 
general  plans  without  special  reference  to  the  points  of  the 
compass.  An  ideal  combination  of  school  and  hospital  in 
close  proximity  would  seem  to  be  possible  without  sacrifice 
to  any  essential  element  of  either  by  securing  a  site  large 
enough  to  place  the  hospital  on  its  southern  and  the  medical 
school  on  its  northern  portion.  The  only  prominent  detail 
remaining  is  the  securing  of  easy  and  sufficient  access  be- 
tween the  correlated  parts  of  the  two  members  in  the  part- 
nership. The  street  plan  of  New  York  lends  itself  ad- 
mirably to  such  a  solution  because  the  long  side  of  the 
city  blocks  runs  east  and  west,  but  it  will  be  found  that 
these  same  conditions  limit  the  choice  of  plans  to  a  con- 
siderable extent.  The  problem  to  be  solved  is  really  a  new 
one  in  New  York  at  least  so  far  as  the  complexity  of  the 
whole  subject  and  most  of  its  details  are  concerned.  Other 
teaching  hospitals  exist,  but  they  are  limited  in  their  scope 
to  some  special  feature  of  medical  education,  either  to  a 
medical  specialty  like  obstetrics  or  to  post-graduate  teach- 
ing. No  large  general  hospital  has  ever  been  built  in  New 
York  which  would  have  a  medical  school  in  close  affiliation. 
The  two  graduate  schools  of  New  York  were  both  built 
to  give  instruction  to  medical  men.  Their  problems,  how- 
ever, are  quite  different  from  the  needs  of  a  school  and 
hospital  designed  especially  for  undergraduate  instruction. 
The  Flower  Hospital  of  the  Homeopathic  school  of  New 
York  was  built  for  an  undergraduate  school  and  undoubt- 
edly meets  many  of  the  demands  for  such  a  hospital.  Its 
site,  however,  is  limited  in  area  and  required  some  limita- 
tion to  the  best  development.  Its  wards  are  placed  on  an 
east  and  west  axis  and  as  is  shown  below  this  in  itself 
is  a  serious  criticism  of  the  general  plan.  The  two  most 
prominent  examples  of  hospitals  built  for  teaching  pur- 
poses are  the  two  large  maternity  hospitals,  the  Sloane 
Hospital  for  Women  and  the  Lying-in  Hospital.  The 
Sloane  was  built  on  the  Corridor  principle  of  small  wards 
of  four  to  six  beds  each  and  its  close  connection  with  the 
College  of  Physicians  and  Surgeons  make  unnecessary  any 
special  provision  for  the  care  of  students  except  a  students' 


dormitory  and  workroom.  The  Lying-in  Hospital  on  the 
contrary  aimed  to  provide  a  complete  residence  and  work- 
room and  a  school  of  instruction  with  library  and  museum 
not  only  for  the  students  to  be  taught  in  the  hospital  wards, 
but  also  to  care  for  the  larger  student  body  who  were 
assigned  to  the  out-patient  service  connected  with  the  hos- 
pital. Although  devoted  to  a  single  branch  of  medicine — ob- 
stetrics, the  Lying-in  Hospital  is  well  worth  a  study  by  any- 
one who  contemplates  designing  a  teaching  hospital.  The 
hospital  was  begun  in  1899  on  plans  which  were  the  result 
of  five  years'  study  of  the  best  hospitals  in  Europe  and 
America.  The  general  design  consists  of  devoting  the 
lower  stories  to  the  school,  to  the  nurses'  home  and  to  the 
hospital  administration,  and  placing  the  wards  in  the  upper 
three  stories.  This  hospital  is  built  around  a  central  court 
and  the  dormitory  quarters  for  staff,  students,  nurses  and 
employees  are  for  the  most  part  in  the  lower  stories  on 
this  central  exposure  and  on  the  north  side  where  the  least 
sunlight  is  to  be  found.  The  ward  details  will  be  referred 
to  again  in  discussing  the  ideal  plan  of  hospital  construc- 
tion. In  general  it  can  be  said  that  the  Lying-in  Hospital 
when  built  came  nearer  to  fulfilling  the  theoretical  require- 
ments for  a  healthy  block  hospital  than  any  of  its  predeces- 
sors and  than  many  of  the  hospitals  built  in  New  York  since 
then  as  well. 

The  Ideal  Hospital:  The  theoretical  improvement  of 
hospital  building  and  the  practical  application  of  proper 
hygiene  to  new  construction  has  interested  the  best  archi- 
tects and  hospital  boards  for  the  past  many  years.  During 
this  time,  however,  some  of  the  worst  examples  of  hospital 
buildings  have  been  planned  and  erected  in  the  same  com- 
munities where  the  study  of  healthy  hospital  construction 
has  been  most  advanced.  Most  faults  in  hospital  archi- 
tecture are  being  repeated  in  new  construction,  not  only 
in  America,  but  in  Europe  coincidentally  with  the  de- 
velopment of  the  best  examples  of  hospital  plants.  The 
most  recent  and  most  scientific  literature  on  this  subject  is 
to  be  found  in  the  German  language  and  the  latest  German 
constructions  are  mostly  to  be  considered  models  of  their 


kind.  Doctor  W.  Oilman  Thompson  has  published  the  con- 
clusions which  he  reached  after  an  extended  study  of  Euro- 
pean hospitals.  The  opening  statement  of  his  paper  is  en- 
lightening: "The  modern  idea  of  the  construction  of  the 
general  hospital  building  is  that  the  building  itself  should 
bear  a  definite  relationship  to  treatment,  that  it  is  more 
than  a  mere  convenient  form  of  lodging  house  for  the 
sick." 

The  success  or  failure  of  any  hospital  plant  depends  not 
upon  the  architectural  beauty  of  its  fagade,  not  upon  the 
scientific  plants  for  research  and  for  diagnosis,  not  upon 
the  auxiliary  departments  for  treatment  of  the  sick,  not 
upon  the  facilities  for  education  of  students  and  nurses, 
and  not  upon  the  conducting  of  a  more  or  less  elaborate  hotel 
for  the  wealthy  invalid.  All  of  these  things  are  essential  to 
the  success  of  a  modern  hospital  but  all  of  them  permit  of  a 
certain  amount  of  elasticity  in  arrangement,  in  organiza- 
tion and  in  their  position  in  the  buildings  relative  to  the 
others.  The  one  great  important  factor  in  hospital  con- 
struction is  the  public  ward.  The  residing  place  for  the 
sick  poor  is  the  element  to  which  all  others  are  secondary 
and  to  which  they  must  yield  precedence  in  demands  for  lo- 
cation, for  size  and  for  arrangement.  The  ward  unit  with 
its  service  rooms  must  be  rightly  placed  and  fitted  up  or 
the  whole  combination  for  therapeutics,  for  diagnosis,  for 
research  and  for  education  will  fail  of  proper  accomplish- 
ment. 

A  healthy  ward  unit  demands  full  circulation  of  air 
around  its  outside  walls;  it  should  be  sheltered  from  the 
north  and  northeast;  it  should  be  raised  above  the  ground 
level;  its  length  should  be  in  general  north  and  south  with 
long  sides  and  windows  to  east  and  west,  both  of  which 
should  have  daily  exposure  to  the  sun;  it  should  have 
cross  ventilation  from  east  to  west;  it  should  contain  beds 
from  12  to  28  in  number,  or  in  some  multiple  of  four;  it 
should  have  at  least  one  window  to  every  two  beds,  pref- 
erably one  to  every  bed. 

The  development  of  hospital  construction  has  been  along 
two  different  lines  known  as  the  pavilion  system  and  the 


corridor  system.  On  a  strict  interpretation  of  these  terms 
the  pavilion  hospital  is  made  up  of  a  series  of  isolated  one- 
story  ward  units  grouped  together  on  a  larger  or  smaller 
plot  of  ground.  It  is  an  outgrowth  of  the  military  barrack 
hospitals  of  temporary  construction,  which  were  the  most 
successful  hospital  plants  in  the  army  service  during  the 
wars  of  the  Middle  Nineteenth  Century  before  the  true 
nature  of  infectious  diseases  and  of  wound  septicamias  was 
discovered.  The  typical  corridor  hospital  in  like  sense  is 
a  more  or  less  lofty  single  building  with  wards  on  each 
story  opening  off  from  long  connecting  passageways  or 
corridors.  Such  a  hospital  is  known  also  as  a  block  hospital. 
The  most  recent  scientific  studies  of  hospital  construc- 
tion have  been  published  in  Germany  under  the  direction 
both  of  architects  and  of  sanitary  engineers  and  physicians. 
The  development  in  Germany  has  been  along  the  line 
of  the  pavilion  plan,  and  new  hospitals  of  this  character 
to  accommodate  1000  to  2000  patients  have  been  brought 
to  successful  completion  in  a  number  of  cities.  The  German 
authorities  admit  of  no  possible  solution  of  this  problem 
except  upon  the  pavilion  system.  The  latest  German  pub- 
lication on  hospital  construction,  issued  under  the  title  of 
Das  Deutsche  Krankenhaus,  discusses  the  advantages 
and  disadvantages  of  both  plans  and  comes  to  the  emphatic 
conclusion  that  small  hospitals  of  50  beds  may  well  be 
built  on  the  corridor  plan,  that  medium-sized  hospitals  up 
to  300  beds  may  also  be  so  constructed  but  usually  at  a 
loss  of  efficiency  in  the  essentials  of  the  ward  unit.  Large 
hospitals,  over  300  beds  in  size,  according  to  this  same  au- 
thority, can  never  be  built  without  serious  and  even  criminal 
neglect  except  upon  a  broad  application  of  the  pavilion  sys- 
tem. The  compiler  of  this  work.  Dr.  Grober,  admits  the 
advantages  of  administration  in  block  hospitals  of  moderate 
size,  but  he  would  limit  the  height  of  such  buildings  to  three 
stories  and  the  number  of  beds  to  120  as  a  maximum  for 
a  single  building,  A  very  recent  study  of  hospital  con- 
struction has  appeared  this  year  in  French.  It  is  entitled 
La  Construction  des  Hopitaux  and  is  written  by  Doctors 
A.  Depage,  P.  Vandervelde  and  V.  Cheval.    Its  conclusions 


are  the  same  as  those  of  the  German  authors,  that  modern 
hospital  construction  can  be  considered  only  on  the  basis 
of  the  pavilion  plan.  American  writers  on  hospital  con- 
struction have  been  influenced  by  this  uncompromising 
view  of  the  German  and  French  scientists,  and  recent 
articles  on  the  subject  have  adopted  the  pavilion  system 
as  the  only  solution  for  large  hospital  plants.  An  im- 
portant element  in  the  question,  at  least  so  far  as  New 
York  City  is  concerned,  is  the  price  of  land.  The  large 
pavilion  hospitals  of  Germany  are  built  upon  plots  of 
ground  which  allow  to  each  patient  in  the  hospital  from 
100  to  500  square  meters  of  hospital  land,  and  this  is  some- 
times increased  by  the  existence  of  a  surrounding  park. 
Such  an  allowance  is  prohibitive  in  New  York  City.  The 
German  and  French  authorities  speak  of  the  possibility 
of  combining  the  corridor  and  pavilion  plans  in  one  struc- 
ture but  for  small  hospitals  only.  Such  a  combination  must 
be  devised  if  a  large  hospital  plant  is  to  be  built  in  New 
York  on  hygienic  healthy  principles.  These  European  au- 
thorities insist  on  the  pavilion  plan  for  large  hospitals  as 
offering  the  only  possible  solution  for  a  hygienic  decen- 
tralization of  the  ward  units  and  they  belittle  the  incon- 
veniences and  the  increased  expenses  for  a  larger  personnel 
which  necessarily  result  from  adopting  a  pavilion  plan  and 
which  are  directly  due  to  the  service  decentralization  of 
such  a  plan.  This  problem  is  far  from  insurmountable. 
Its  solution  consists  in  securing  as  complete  an  isolation 
of  each  ward  unit  from  every  other  as  is  secured  by  sep- 
arate isolated  one-story  ward  pavilions,  and  this  solution 
must  be  applied  not  only  to  the  ward  units  on  different 
stories  but  to  those  on  the  same  level.  This  can  be  done 
successfully  so  that  the  external  contour  of  the  buildings 
does  not  obstruct  the  free  use  of  air  and  sun  in  the  wards 
and  so  that  the  connecting  corridors  on  each  floor  do  not 
present  an  unobstructed  communication  between  wards  and 
so  that  the  stairways  and  elevator  shafts  for  personnel 
and  for  service  do  not  offer  a  direct  conduction  of  air,  of 
noise  and  of  dust  between  floors.  If  this  be  done  there  is 
no  reason  why  the  various  "ward  pavilions"  of  the  hospital 


should  not  be  placed  one  above  the  other  for  any  number 
of  stones  with  the  same  hygienic  success  as  results  from 
building  these  pavilions  side  by  side  in  an  indefinitely  large 
plot  of  ground.  American  architects  have  solved  the  prob- 
lem of  the  skyscraper  business  building,  and  the  same  steel 
construction  can  be  applied  to  hospitals.  The  essentials 
have  been  accomplished  in  New  York  in  at  least  two 
different  fashions,  one  of  which  is  represented  by  the 
Mt.  Sinai  and  the  St.  Luke's  Hospitals  and  the  other  by  the 
Lying-in  Hospital.  Probably  both  of  these  can  be  still 
further  improved  upon. 

As  already  pointed  out,  the  essential  element  in  hospital 
construction  is  the  ward  unit.  The  ward  of  a  hospital  must 
be  constructed  to  fulfill  certain  conditions  of  external  rela- 
tions as  well  as  possess  certain  internal  arrangements  if  it 
is  to  serve  its  purpose  in  a  satisfactory  and  hygienic  man- 
ner. The  external  relation  of  a  ward  to  the  points  of  the 
compass  to  the  other  parts  of  the  hospital  and  to  neighbor- 
ing buildings  and  to  the  surrounding  streets,  will  influence 
the  access  of  sunlight  and  of  air,  and  also  the  freedom 
from  dust  and  smoke  quite  independent  of  the  size  of  the 
wards.  All  the  best  authorities  agree  that  in  order  to 
fulfill  these  conditions  the  ward  should  be  rectangular ;  that 
it  should  have  windows  on  both  long  sides ;  that  its  long 
axis  should  be  in  the  general  north  and  south  direction ; 
that  all  auxiliary  rooms  and  connecting  corridors  should  be 
on  the  north  end,  that  its  south  end  should  be  free  of  all 
attachments  except  that  possibly  a  balcony  or  day  sun 
room  for  patients  might  be  situated  there.  This  ideal  ward 
must  have  no  obstruction  to  the  south  of  it  to  cut  off  the 
free  approach  of  direct  rays  of  the  sun  to  its  eastern  wall 
during  the  morning  and  to  the  western  wall  in  the  after- 
noon. This  protection  from  shadows  refers  to  the  adjacent 
ward  pavilions  and  other  hospital  buildings  as  well  as  to 
neighboring  structures.  If  the  sunlight  be  unobstructed 
it  is  fair  to  assume  that  the  currents  of  air  will  be  sufficiently 
free  of  access  and  windows  on  the  two  long  sides  will 
ensure  a  natural  cross  ventilation.  The  site  of  the  hospital 
should  be  selected  as  far  as  possible  at  a  distance  from 


large  factories,  and  especially  from  electric  power  and  gas 
plants,  in  order  that  the  possibility  of  nuisance  from  smoke 
and  cinders  and  dust  may  be  reduced  to  a  minimum.  Two 
hospitals  in  New  York  have  protected  their  southern  ex- 
posure by  securing  building  sites  on  the  north  side  of  a 
public  park,  namely  the  New  York  Hospital  at  its  new 
site  and  the  Lying-in  Hospital.  Other  hospitals  in  the 
city  have  built  on  the  river  front,  which  assures  light  and 
air,  although  the  open  space  is  not  always  on  the  southerly 
exposure.  But  almost  none  of  the  metropolitan  hospitals 
have  wards  designed  on  this  model  as  approved  by  most 
authorities. 

In  New  York  only  a  few  examples  can  be  found  of  wards 
which  approach  the  ideal  here  described.  The  original 
plans  of  Roosevelt  Hospital  called  for  such  an  arrangement, 
and  some  of  its  older  wards  approach  this  plan,  but  subse- 
quent buildings  have  encroached  upon  the  original  hospital 
scheme  in  a  medley  of  architectural  and  hygienic  ideas. 
One  series  of  superimposed  wards  at  the  Lying-in  Hospital 
was  designed  to  fulfill  this  condition,  and  presents  a  good 
example  of  what  can  be  done  even  upon  a  site  the  shape 
of  which  is  not  the  most  favorable  for  an  ideal  hospital. 
Many  New  York  hospitals  have  wards  of  which  the  long 
axis  runs  east  and  west,  this  results  in  a  warm,  sunny 
south  side  and  a  cold,  dark  north  side.  The  present  New 
York  Hospital  has  some  of  the  best  wards  of  this  kind 
to  be  found  anywhere;  these  wards,  built  thirty-five  years 
ago,  have  preserved  their  usefulness  because  they  have  been 
able  to  borrow  sunlight  from  a  large  private  garden  in 
front  of  the  hospital.  Other  hospitals,  like  St.  Luke's  and 
Mt.  Sinai,  have  wards  with  a  three-sided  exposure,  of  which 
the  south  is  the  longest  and  the  east  and  west  comparatively 
short,  while  the  whole  north  side  is  for  connection  with 
the  main  buildings.  Such  wards  do  not  lack  sunlight,  but 
there  is  not  a  good  through  and  through  natural  cross  ven- 
tilation. Circular  and  octagonal  wards  have  been  suggested 
and  tried  out,  for  example,  at  the  General  Memorial  Hos- 
pital. They  are  probably  somewhat  easier  of  internal  admin- 
istration for  the  nursing  service  but  the  radial  arrangement 


of  the  beds  will  interfere  with  the  use  of  stretchers,  although 
of  advantage  in  separating  the  heads  of  the  patients  one 
from  another.  They  are  difficult  to  fit  into  a  large  hospital 
plant  without  waste  of  space  and  they  present  difficulties  in 
ventilation  as  well  unless  they  are  in  single-story  pavilions. 
Circular  wards  cannot  be  built  for  more  than  twelve  beds 
except  they  become  of  an  unwarranted  size. 

A  number  of  plans  have  been  suggested  recently  for 
hospital  ward  units  which  are  somewhat  bizarre  in  con- 
ception. The  plans  published  in  the  International  Hospital 
Record  (May,  1911),  for  a  new  hospital  at  Stamford,  Con- 
necticut, are  more  odd  than  practicable ;  the  north  and  south 
axis  is  suggested,  but  the  north  end  is  so  surrounded  by 
the  subsidiary  ward  rooms  that  some  six  beds  at  that  end 
of  the  ward  would  have  no  direct  relation  to  windows  and 
are  placed  in  what  amounts  to  a  deep  alcove.  Such  a  plan 
is  viciously  conceived  and  outrages  the  principles  of  bed 
arrangement  which  is  discussed  below. 

It  is  exceedingly  difficult  to  understand  plans  of  hos- 
pitals as  presented  in  most  publications  because  the  points 
of  the  compass  are  not  indicated  upon  the  plans,  and  a 
knowledge  of  the  direction  of  the  north  and  south  axis  of 
the  proposed  buildings  is  absolutely  essential  to  an  intelli- 
gent understanding  of  hospital  drawings.  This  is  true  both 
in  regard  to  the  ward  unit  itself  and  in  regard  to  the  possi- 
ble darkness  or  light  of  the  re-entering  angles  behind  and 
between  the  separate  hospital  buildings  which  make  up  the 
total  plant. 

The  internal  arrangements  of  the  ideal  hospital  ward  are 
equally  important  with  its  external  environment.  In  the 
plan  for  the  external  relations  of  the  hospital  ward,  which 
is  developed  above,  all  the  medical  auxiliary  rooms  must 
be  grouped  about  the  north  end  of  the  ward.  There  is  a 
single  exception  to  this  arrangement  so  far  as  a  room  or 
balcony  for  the  outdoor  treatment  of  acute  disease  or  for 
the  convalescent  treatment  of  many  patients  is  concerned. 
This  must  have  as  much  sun  exposure  as  is  possible,  and 
can  be  located  at  the  most  southerly  end  of  the  ward 
unit  provided  it  is  so  constructed  as  not  to  cast  a  shadow 

10 


on  the  side  walls  of  the  ward.  The  rooms  which  must  be 
connected  with  each  ward  are  a  day  room,  one  or  two  isola- 
tion rooms  for  single  patients,  a  bath  room,  toilets,  a  diet 
kitchen,  a  dining  room  for  convalescents,  a  linen  room,  a 
work  room  for  the  nurses,  an  examining  room  and  a  bal- 
cony for  fresh  air  treatment.  There  should  be  an  office 
and  work  room  for  the  attending  staff,  another  for  the 
resident  staff  and  student  clerks  and  a  laboratory  for  rou- 
tine clinical  pathology  for  each  group  of  wards  under  a 
single  professional  control.  These  rooms  should  be  grouped 
about  the  general  connecting  corridors  and  stair  and  eleva- 
tor service  shafts  at  the  north  end  of  the  ward.  The  ward 
and  its  service  auxiliaries  should  be  isolated  from  the 
rest  of  the  institution  by  a  set  of  doors  in  the  corridors 
and  the  whole  system  of  stairways  and  elevator  shafts 
should  be  so  separated  that  they  can  in  no  way  serve  as 
a  direct  and  constant  source  of  communication  for  noise 
and  air  between  the  individual  ward  units  and  the  rest  of 
the  hospital  plant.  This  prevention  of  direct  communica- 
tion through  the  necessary  avenues  of  intercourse  forms 
the  essential  detail  of  that  hygienic  decentralization  which 
is  so  much  sought  after  by  the  modern  hospital  architects 
in  Europe.  This  can  be  secured  in  a  block  pavilion  hospital 
equally  successfully  if  not  as  easily  as  in  a  cottage  pavilion 
hospital  of  the  European  type.  In  Figure  1  an  attempt 
has  been  made  to  plan  a  typical  ward  unit  in  which  the 
ideals  here  indicated  are  in  some  measure  fulfilled,  although 
it  is  beyond  the  scope  of  this  paper  to  detail  the  plans  for 
a  complete  hospital.  This  plan  for  a  ward  unit  presents 
the  following  points:  The  sun  balcony  is  a  continuation 
to  the  south  of  the  same  diameter  as  the  ward  itself.  The 
ward  with  its  medical  service  appendages  abuts  on  the 
northern  end  the  general  connecting  corridor  which  runs 
east  and  west  and  which  separates  these  portions  of  the 
ward  unit  from  the  stairways,  elevator  shafts  and  rooms 
for  education. 

Of  the  many  plans  of  hospitals  which  have  been  pub- 
lished recently  that  of  the  new  general  hospital  in  Cin- 
cinnati   presents    a    ward    unit    which    approximates    this 

11 


plan  as  shown  in  Figure  1.  The  Cincinnati  hospital,  how- 
ever, has  a  large  plot  of  ground  at  its  disposal,  and  will 
build  its  wards  in  blocks  of  three  superimposed  units  on 
much  the  same  plan  as  the  new  Charite  in  Berlin  and  the 
new  hospital  in  Munich  (International  Hospital  Record,  June, 
1911). 

In  addition  a  few  points  which  are  frequently  neglected 
may  also  be  referred  to.  The  bath  room  should  be  fitted 
to  handle  the  movable  tubs  which  are  needed  in  bedside 
bathing,  especially  of  typhoid  fever  cases,  for  the  ordinary 
stationary  tub  of  a  private  house  has  but  a  limited  use 
in  hospital  practice.  The  toilets  also  should  be  planned 
to  handle  the  bed  service  in  an  adequate  manner.  The 
toilet  rooms  should  be  separated  from  the  ward  by  a  vesti- 
bule which  should  have  window  ventilation  and  light,  and 
that,  too,  not  giving  upon  a  shaft  but  out  of  doors.  These 
necessary  appendages  to  the  ward  unit  have  frequently  been 
built  in  a  very  cramped  manner  and  of  inadequate  size. 
The  addition  of  balconies  for  the  open  air  treatment  of 
acute  diseases  to  a  general  medical  or  surgical  ward  is 
a  modern  necessity,  but  they  should  not  be  built  so  that 
they  cut  ofif  the  sunlight  and  air  from  the  ward  itself. 
Special  outdoor  wards  separate  from  the  regular  wards 
were  a  better  solution  of  the  problem  than  that  these 
balconies  should  destroy  the  hygienic  environment  of  the 
regular  ward  units.  One  of  the  greatest  difficulties  in 
ward  construction  has  been  the  question  of  floor  material. 
One  must  beware  of  newly  patented  devices.  The  last 
written  word  is  strongly  in  favor  of  tiling,  which  has  been 
used,  discarded  and  now  comes  into  favor  again. 

The  internal  distribution  of  the  beds  in  a  ward  will 
determine  its  shape,  and  the  number  of  beds,  its  size. 
Expert  opinion  is  almost  unanimously  in  favor  of  arrang- 
ing the  beds  along  parallel  walls  so  that  the  head  of  each 
bed  is  against  but  separated  by  a  short  interval  from  the 
wall  and  that  each  bed  shall  be  between  two  windows.  The 
least  floor  space  which  has  been  suggested  by  any  reliable 
expert  is  the  8  feet  of  ward  length  by  13^^  feet  of  ward 
width  by  Douglas  Galton.     This  would  represent  a  rec- 

12 


tangular  ward  27  feet  wide  in  the  clear  and  8  feet  long 
for  every  two  beds,  e.  g.,  a  ward  of  20  beds  would  be  80 
feet  long.  This  allowance  of  width  gives  room  for  central 
tables  and  a  free  stretcher  service,  it  is  a  minimum  require- 
ment. Continental  authorities  agree  quite  closely  with  this 
estimate  of  Galton's.  The  length  per  bed  varies  but  little, 
and  the  ward  width  only  from  27  to  31  feet.  The  average 
number  of  beds  in  a  single  ward  is  20,  the  number  may 
vary  advantageously  in  multiples  of  four  since  four  beds 
represents  the  number  which,  when  devoted  to  an  acute 
service,  will  require  an  additional  nurse  for  the  proper  care 
of  the  patients.  In  a  chronic  service  or  one  for  lesser  ail- 
ments six  beds  may  be  considered  as  the  nurse-bed  unit. 
A  ward  of  24  beds  therefore  could  be  used  advantageously 
either  for  an  acute  or  a  chronic  service  and  cared  for  by 
four  or  six  nurses,  as  seemed  desirable,  and  24  would 
seem  to  be  a  rational  number  of  beds  for  a  single  ward. 

The  cubic  space  per  patient  would  determine  the  height 
of  the  ward.  Doctor  Grober,  in  Das  Deutsche  Kranken- 
haus,  warns  against  too  high  a  ceiling,  especially  men- 
tioning 16  to  19  feet  as  having  been  tried  and  found  unde- 
sirable; 15  feet  is  generally  conceded  as  a  desirable  height. 
A  ward  of  24  beds  should  be  96  feet  long,  28  feet  wide  and 
15  feet  high,  and  would  possess  112  square  feet  and  1,680 
cubic  feet  per  bed,  which  is  a  liberal  allowance.  The 
majority  of  wards  in  New  York  hospitals  do  not  conform 
to  this  ideal  in  internal  arrangement  any  nearer  than  they 
do  in  their  external  relations.  Many  of  them  are  wider, 
have  beds  on  all  four  walls  and  with  no  relation  to  the 
window  plan,  and  others  are  almost  square,  and  one  hospital 
has  circular  wards.  The  present  New  York  Hospital  has 
an  ideal  ward  in  many  particulars,  the  wards  of  the  Lying- 
in  Hospital,  except  for  an  architect's  error  in  making  one 
series  less  than  27  feet  wide,  and  the  larger  Roosevelt  wards, 
also  are  planned  on  this  general  interior  layout,  and  all 
have  proved  the  wisdom  of  their  designers. 

If  one  applies  these  principles  to  the  building  of  a 
hospital  in  New  York  it  will  be  found  not  only  that  the 
ideal  plan  for  the  ward  unit  can  be  carried  out  in  every 

13 


particular  but  that  this  ideal  plan  offers  the  best  solution 
for  hospital  construction  except  the  building  of  a  small 
institution  of  a  hundred  beds  or  less  is  under  consideration. 
The  single  plots  of  land  or  blocks  between  streets  have 
a  rectangular  shape  with  a  short  side  about  200  feet  long  on 
the  east  and  west  and  a  long  axis  of  varying  length  some- 
times over  900  feet.  Such  blocks  of  land  would  seem  to 
compel  the  adoption  of  this  plan  for  wards  running  north 
and  south  in  superimposed  groups  at  regular  intervals  one 
from  the  other,  and  yet  of  all  the  hospitals  in  the  city 
which  own  a  sufficiently  large  site  or  a  whole  block  Roose- 
velt alone  started  with  such  a  plan,  and  the  Roosevelt 
authorities  have  done  their  best  to  destroy  by  subsequent 
building  the  original  advantages  inherent  in  its  plan.  The 
New  York  City  block  offers  to  the  south  the  best  exposure 
to  air  and  sun  that  can  be  found  in  any  city,  and  the  higher 
placed  the  ward  may  be  the  greater  these  advantages  be- 
come. This  plan  is  no  very  new  discovery  in  hospital  con- 
struction, but  was  formulated  authoritatively  over  forty 
years  ago,  and  the  Roosevelt  Hospital  architect  did  not 
necessarily  happen  on  it  by  a  happy  chance.  The  plan  of 
a  tall  building  along  the  northerly  long  side  of  the  city 
block  in  which  all  administrative  and  the  more  strictly 
medical  work  should  be  done  and  with  wings  running  from 
this  main  building  to  the  south  to  contain  the  superimposed 
wards  and  their  adjunct  apartments  should  have  been  recog- 
nized long  ago  not  only  as  a  proper  solution  of  the  hygienic 
problems  of  hospital  construction  but  also  as  New  York's 
specific  contribution  to  those  problems. 

In  the  past  new  hospitals  have  been  built  too  often  by 
architects  who  are  studying  the  problem  for  the  first  time, 
and  New  York  City  institutions  are  suffering  from  this 
failure  to  benefit  from  past  experience  in  hospital  buildings. 
New  York  is  not  alone  in  this  respect,  for  Dr.  Grober,  in  his 
study  of  hospitals  in  Germany,  laments  that  "old  errors 
have  been  constantly  repeated  in  new  buildings."  The  plan 
proposed  is  outlined  in  Figure  2,  which  is  drawn  to  occupy 
a  block  200  feet  from  north  to  south  and  450  feet  from  east 
to  west.     It  will  admit  of  an  indefinite  extension  in  the 

14 


east  and  west  axis  by  the  addition  of  further  ward  unit 
pavilions.  The  northern  main  building  is  represented  here 
as  a  solid  building  which  can  be  broken  in  the  upper  stories 
for  individual  ward  units  connected  by  corridor  bridges 
which  will  facilitate  the  circulation  of  air  currents  between 
the  pavilions.  This  arrangement  of  the  upper  stories  is 
shown  in  Figure  3.  This  whole  structure  would  contain, 
with  the  four  ward  unit  pavilions  shown,  100  patients  on 
each  floor,  24  in  each  ward  and  one  in  the  isolation  room 
of  that  ward.  All  the  lower  parts  of  the  building  would  be 
given  up  to  administration  and  no  patients  would  be  housed 
until  the  upper  floors  were  reached.  If  300  patients  were 
desired  there  would  be  three  upper  floors  for  patients,  and  if 
four  floors  were  needed  to  administer  and  house  the  attend- 
ants needed  to  care  for  300  patients  the  whole  building 
would  be  seven  stories  high.  If  five  lower  stories  were 
needed  for  such  extra  medical  uses  the  whole  structure 
would  have  to  be  eight  stories  high.  The  lower  floors  of 
such  a  building,  especially  on  its  north  front,  would  be 
darker  and  sunless  as  compared  with  the  upper  ward  floors, 
and  it  is  in  such  location  that  one  should  place  the  dormi- 
tories for  employees,  and  such  rooms  as  needed  only  venti- 
lation without  reference  to  outlook  and  to  sunshine. 

The  Lying-in  Hospital  did  not  possess  a  properly  shaped 
piece  of  land  to  adopt  this  plan  in  its  entirety  but  the 
arrangement  of  its  several  stories  is  designed  on  these  prin- 
ciples and  though  it  is  a  hospital  of  only  200  beds  it  may 
well  serve  in  many  particulars  as  a  model.  At  least  one 
large  hospital  has  been  built  on  this  plan  just  described 
as  the  ideal  one  for  New  York  and  carried  to  a  logical  com- 
pletion. Saint  Thomas'  Hospital  in  London  is  such  a 
hospital,  but  it  fails  of  securing  all  the  advantages  possible 
in  a  New  York  structure  because  the  plot  of  ground  is  so 
placed  in  regard  to  the  River  Thames  that  the  axis  of  the 
ward  units  runs  almost  due  east  and  west  and  the  connect- 
ing main  building  cuts  oflf  the  eastern  sun  exposure.  The 
architects  evidently  have  thought  more  of  the  air  currents 
and  free  space  towards  the  River  Thames  than  of  the  alter- 
nating sunshine  on  the  two  sides  of  the  rectangular  wards 

15 


which  would  have  been  made  possible  by  a  north  and  south 
ward  unit  axis.  Nevertheless,  the  general  plan  of  Saint 
Thomas  can  serve  as  an  example  of  the  development  of 
which  such  a  plan  is  capable.  The  new  Bellevue  in  New 
York  has  a  different  general  plan  and  the  same  error  has 
been  committed  of  seeking  sun  and  air  from  a  river  on 
the  east  of  the  site  and  not  from  a  proper  consideration  of 
the  points  of  the  compass. 

An  interesting  solution  of  this  problem  has  been  reached 
by  the  Building  Committee  of  the  Peter  Bent  Brigham 
Hospital  in  Boston.  This  new  institution  will  furnish  a 
general  hospital  for  the  educational  work  of  the  Harvard 
Medical  School.  The  site  is  a  magnificent  one  and,  while 
somewhat  irregular  in  shape,  it  is  more  than  1200x300  feet 
in  size,  with  the  long  axis  in  the  general  east  and  west 
direction.  It  is  proposed  to  provide  eventually  for  about 
350  patients  on  this  site  and  the  general  plan  of  ward  unit 
pavilions  running  north  and  south  and  connected  along  their 
north  ends  with  the  administrative,  educational  and  scien- 
tific parts  of  the  hospital  has  been  adopted.  A  novel  scheme 
has  been  applied  to  each  pavilion  by  which  each  story  has 
a  less  length  than  the  one  below  it.  In  this  way  each  ward 
uses  the  southern  part  of  the  roof  of  the  ward  below  it  as 
a  sunning  veranda  for  the  convalescent  patient  or  for  out- 
door treatment.  These  ward  pavilions  are  only  three  stories 
high  at  their  north  end  and  one  story  at  the  south.  Such 
a  general  plan  is  possible  only  when  a  large  plot  of  ground 
is  available,  and  this  hospital  is  practically  a  pavilion  hos- 
pital in  the  European  sense. 

Nothing  is  to  be  gained  by  a  detailed  statement  of 
the  general  plans  of  the  large  European  pavilion  hospitals, 
though  much  can  be  learned  from  a  study  of  the  ward  units 
and  their  internal  arrangements.  It  is  especially  important 
that  the  designs  of  European  manufacturers  of  hospital 
furniture  and  of  plumbing  and  household  fixtures  for  hos- 
pitals, as  well  as  of  scientific  instruments,  be  thoroughly 
studied. 

The  Ideal  Medical  School:  The  plans  for  developing 
this  hospital-university  alliance  must  include  in  addition  to 

16 


a  model  hospital  also  a  scheme  for  ideal  buildings  for  a 
school  of  medicine.  Such  a  school  must  provide  for  the 
rooms  necessary  for  administration  both  of  the  school  itself 
and  of  the  several  departments,  also  for  instruction  in  lec- 
ture, recitation  and  laboratory  work.  There  must  be  labor- 
atories for  research  and  departmental  libraries.  The  build- 
ings should  be  capable  of  extension  to  accommodate  any 
new  feature  in  medical  science  which  may  be  demanded 
within  a  reasonable  future  time.  Such  a  new  development 
is  needed  to-day  in  the  form  of  a  considerable  plant  for 
sanitary  science  and  preventive  medicine  and  provision 
should  be  made  for  this  comparatively  new  science  allied 
to  medicine.  Rooms  for  a  medical  museum  both  for  general 
museum  purposes,  the  storing  of  unusual  specimens  and 
also  for  teaching  students  in  the  class  rooms.  The  school 
must  provide  quarters  for  the  students  upon  collegiate 
lines.  Not  only  study  rooms  and  a  students'  library  should 
be  provided  in  the  college  buildings  but  also  the  school 
must  supply  residence  halls,  recreation  rooms  and  a  gymna- 
sium and  facilities  for  exercise.  The  position  of  the  build- 
ings of  a  medical  school  in  reference  to  the  points  of  the 
compass  demands  the  exact  reverse  of  what  is  needed 
by  the  hospital.  The  controlling  requirement  of  the  ideal 
school  is  the  need  of  its  laboratories  of  education  and  re- 
search for  direct  and  unimpeded  skylight.  The  direct  rays 
of  the  sun  are  a  distinct  disadvantage  in  the  use  of  the 
microscope  and  most  optical  instruments,  so  that  the  expo- 
sure of  the  windows  of  the  working  rooms  of  a  school  of 
medicine  must  be  towards  the  north.  In  order  to  increase 
this  the  buildings  should  be  planned  with  wings  and  exten- 
sions on  the  northern  fagade  in  the  exact  reverse  of  the 
arrangement  proposed  above  for  the  plan  of  the  ideal  hos- 
pital. If  one  applies  this  principle  of  construction  to  the 
street  and  block  plan  of  New  York  City  one  would  prefer 
a  site  which  ran  through  from  one  side  street  to  another 
and  occupied  as  much  of  a  city  block  as  might  be  needed. 
One  would  then  adopt  a  ground  plan  for  the  medical  school 
which  would  consist  of  a  main  building  on  the  southerly 
side  of  the  site  with  perhaps  some  breaks  for  entrance  of 

17 


light  on  that  side  but  surely  with  broad  and  rather  shallow 
extensions  on  the  northerly  side.  Such  a  building  is  out- 
lined in  Figure  3,  and  this  plan  would  secure  a  maximum  of 
light  and  air  on  the  northern  exposure.  In  Figure  3  also  the 
combination  of  school  on  the  north  and  hospital  on  the 
south  is  shown.  And  the  hospital  is  represented  on  its 
upper  or  ward  unit  floors.  There  have  been  many  build- 
ings either  remodeled  or  built  for  the  express  purpose  of 
serving  as  schools  of  medicine  in  New  York,  and,  in  fact, 
the  College  of  Physicians  and  Surgeons  has  occupied  six 
homes  during  its  100  years'  existence.  No  one  of  all  these 
buildings  has  ever  been  planned  with  an  intelligent  under- 
standing both  of  the  needs  of  a  school  and  of  the  physical 
conditions  of  the  street  plan  of  New  York  City. 

To  plan  an  ideal  combination  of  hospital  and  school  with 
particular  reference  to  New  York  City  conditions  will  re- 
quire consideration  of  several  possible  combinations.  The 
hospital  and  the  school  may  occupy  adjacent  blocks  either 
east  and  west  or  north  and  south  of  each  other.  If  north 
and  south  sites  can  be  secured  it  might  be  possible  to  close 
the  intervening  street  to  traffic  and  make  the  combined 
hospital  and  college  sites  practically  one  and  the  same. 
The  city  traffic  in  the  north  or  south  direction  is  so  im- 
portant that  a  similar  plan  could  not  be  brought  about 
for  a  combined  site  on  the  east  and  west  of  a  city  avenue. 
Both  institutions  could  be  placed  on  the  same  site  by  erect- 
ing a  typical  "skyscraper"  building  and  placing  the  hospital 
on  top  of  the  school.  A  building  15  stories  high  might  be 
erected  for  this  purpose,  and  would  present  no  structural 
difficulties,  although  the  best  interests  of  both  hospital  and 
school  could  be  served  by  a  separation  of  the  two.  This 
solution  by  superposition  was  adopted  by  the  Lying-in 
Hospital,  and  was  a  success  in  that  case  because  the  de- 
mands of  a  "school"  of  obstetrics  are  limited,  and  being 
known  beforehand  can  be  planned  for.  In  the  case,  how- 
ever, of  a  large  general  hospital  and  a  university  school  of 
medicine  such  a  plan  would  necessarily  hamper  the  sub- 
sequent growth  of  both  the  school  and  the  hospital  and  it 
should  not  be  adopted,  for  no  one  can  foresee  many  devel- 

18 


opments   which   will  surely   arise  in  medical   science   and 
education  even  in  the  immediate  future. 

The  best  plan  is  the  selection  of  two  sites  lying  north 
and  south  of  each  other  in  order  that  the  hospital  may  be 
placed  on  the  southerly  block  with  a  straight  fagade  to  the 
north  and  the  wings  for  the  ward  unit  pavilions  running  to 
the  south.  The  school  will  then  be  located  on  the  northerly 
block  with  a  more  or  less  straight  fagade  to  the  south  and 
the  broad  laboratory  structures  extending  northward  from 
the  main  building.  It  will  then  be  possible  to  connect  the 
two  allied  institutions  by  tunnels  or  bridges  on  any  stories 
that  may  seem  desirable  quite  irrespective  of  the  fact 
whether  the  separating  street  be  open  as  a  thoroughfare 
or  closed  to  city  traffic.  And  such  a  combination  is  shown 
in  Figure  3  as  has  been  already  pointed  out. 

Available  Sites:  The  alliance  of  the  Presbyterian  Hos- 
pital and  the  College  of  Physicians  and  Surgeons  brought 
together  two  institutions  which  had  each  developed  partial 
plans  for  its  own  expansion  and  rebuilding.  The  hospital 
had  secured  a  site  on  Avenue  A,  between  that  street  and 
the  East  River,  and  between  67th  and  68th  Streets.  This 
site  is  about  300  by  500  feet  in  size  and  irregularly  rec- 
tangular in  shape.  Columbia  University  had  secured  part 
of  a  site  in  116th  Street,  between  Amsterdam  Avenue  and 
Morningside  Park,  and  adjacent  to  the  rest  of  the  Univer- 
sity for  rebuilding  the  College  of  Physicians  and  Surgeons. 
The  completed  site  would  be  about  200  by  400  feet  in  size. 
In  offering  the  following  discussion  of  these  sites  a  single- 
minded  purpose  has  controlled  the  expression  of  the  views 
held  and  of  the  conclusions  reached  by  considering  all  the 
points  in  favor  and  against  the  several  possible  solutions  of 
the  problem  presented.  That  single-minded  purpose  is  to 
assist  both  the  hospital  and  the  university  to  develop  the 
best  possible  teaching  and  philanthropic  institution  and  to 
prevent  any  compromise  which  will  lead  to  an  inferior 
result  which  should  not  be  tolerated  by  either  college  or 
hospital.  The  first  general  axiom  to  be  formulated  is  that 
there  should  be  a  new  hospital  and  a  new  school  and  that 
these  two  must  be  placed  in  close  proximity  one  to  the 

19 


other.  The  question  of  propinquity,  or  adjacency  as  it 
may  be  called,  can  admit  of  no  difference  of  opinion.  If 
the  hospital  is  to  be  built  on  its  67th  Street  site  it  should 
be  done  only  on  the  assumption  that  the  school  of  medicine 
shall  be  rebuilt  also  in  the  same  immediate  neighborhood. 
If  lack  of  funds  cannot  bring  about  such  a  rebuilding  of 
both  institutions  at  the  same  time  at  least  the  land  for 
both  must  be  secured  and  the  plans  for  both  must  be  pre- 
pared even  down  to  small  details  before  any  active  work  is 
undertaken  on  either  school  or  hospital  plants.  This  is  more 
true  of  a  hospital  than  of  any  other  building  enterprise,  and 
is  well  expressed  in  Dr.  Grober's  work  on  The  German 
Hospital  as  follows:  "The  erection  of  a  hospital  should 
not  be  begun  until  a  general  and  complete  program  for  the 
building  plan  has  been  set  forth  even  to  the  minutest  detail." 
It  is  more  than  doubly  true  for  the  double  plant  of  a  hospital 
and  a  school.  It  is  wise  to  consider  both  sites,  that  at  67th 
Street  and  East  River,  and  that  at  116th  Street  and  Morn- 
ingside  Park,  from  the  viewpoint  both  of  the  hospital  and 
of  the  school,  but  especially  of  the  combined  plant. 

The  67th  Street  site  is  bordered  on  the  east  by  the  river, 
looking  over  to  Blackwells  Island  and  its  city  hospitals,  on 
the  south  by  the  vacant  land  and  buildings  of  the  Rocke- 
feller Institute,  on  the  north  by  a  large  brewery  which 
occupies  the  whole  length  of  the  block,  and  on  the  west  by 
some  lots  of  land  across  Avenue  A,  which  are  at  present 
vacant.  When  this  land  was  acquired  by  the  hospital  there 
was  no  thought  of  any  future  alliance  with  Columbia,  either 
for  educational  or  for  scientific  work.  On  the  contrary, 
there  existed  an  intimate  but  loose  connection  between  the 
pathological  department  of  the  hospital  and  the  Rockefeller 
Institute.  The  site  was,  therefore,  a  logical  one  to  secure 
for  a  new  hospital  site.  It  had  many  advantages  as  a  hos- 
pital site  and  it  has  them  yet.  This  nearness  of  the  Rocke- 
feller Institute  is  an  excellent  asset  for  any  general  hospital. 
This  Institute  is  bound  to  become  one  of  the  greatest 
centers  of  medical  research  in  the  world,  and  even  in  its 
short  life  of  ten  years  it  has  already  built  up  an  enviable 
reputation.    Nearness  to  this  center  is  an  excellent  asset  for 

20 


a  school  of  medicine.  And  for  the  combined  institution, 
which  must  be  proposed  and  planned  by  this  Columbia- 
Presbyterian  alliance,  such  a  nearness  of  plants  must  de- 
velop into  a  close  relation  for  the  best  interest  of  hospital, 
of  school  and  equally  too  of  the  Rockefeller  Institute  itself. 
This  site  fulfills  all  the  theoretical  requirements  of  an  ideal 
hospital  site.  It  will  secure  good  air  and  light,  and  a  south- 
ern exposure  which  will  probably  never  be  seriously  threat- 
ened by  the  development  of  the  Rockefeller  Institute.  It 
is  situated  in  a  tenement  district  and  is  in  the  district  which 
has  always  been  served  by  the  Presbyterian  Hospital  wards 
and  the  hospital  ambulance  service.  , 

The  site  under  discussion,  however,  has  some  practical 
defects  which  are  more  or  less  serious.  Although  it  is  in  the 
present  Presbyterian  Hospital  district  it  is  on  the  edge  of 
that  district  and,  being  situated  on  the  East  River,  it  can 
never  become  more  central  than  now,  even  by  a  redistrict- 
ing  of  the  city.  This  is  of  little  consequence,  perhaps,  but  a 
more  serious  objection  is  found  in  the  present  comparative 
inaccessibility  of  this  East  River  site  both  for  patients 
and  for  the  friends  and  patrons  who  are  the  sources  of  the 
hospital's  financial  support.  The  nearest  north  and  south 
car  line  is  on  First  Avenue,  one-seventh  of  a  mile  distant 
(800  feet),  and  there  is  no  available  crosstown  line  at  all. 
This  would  be  quite  a  change  from  the  present  hospital 
site,  which  is  also  on  the  edge  of  its  district  but  situated 
in  a  prominent  residential  quarter  of  the  city.  The  influence 
of  this  present  site  in  securing  recently  some  large  testa- 
mentary bequests  from  previously  unknown  benefactors 
and  in  attracting  financial  support  in  general,  cannot  be 
accurately  estimated,  but  that  it  has  had  an  important 
influence  in  the  past  can  scarcely  be  denied. 

A  recent  development  in  the  system  of  ambulance  service 
districts  in  New  York  is  of  considerable  interest  and  sig- 
nificance in  regard  to  the  future  value  of  hospital  sites  in 
general  and  of  this  site  on  the  East  River  in  particular. 
The  Presbyterian  Hospital  has  served  for  many  years  with 
its  ambulance  equipment  the  district  between  59th  Street 
and  110th  Street,  Central  Park  West  and  the  East  River. 

31 


The  service  has  always  been  done  at  the  expense  of  the  hos- 
pital without  expense  to  the  city  and  in  an  eminently  effi- 
cient and  satisfactory  manner.  The  city  authorities  have 
recently  taken  away  from  the  Presbyterian  Hospital  the 
best  portion  of  this  district  and  allotted  it  to  the  City  Hos- 
pital on  Blackwells  Island.  It  is  entirely  irrelevant  to  this 
discussion  and  perhaps  only  a  question  for  expert  difference 
of  opinion  that  cases  of  acute  disease  in  this  district  would 
be  better  off  if  taken  a  mile  distant  to  the  Presbyterian 
Hospital  for  treatment  according  to  the  former  system  than 
that  they  should  be  taken  first  to  a  reception  hospital  on 
the  Manhattan  side  of  the  East  River  and  then  transferred 
by  boat  to  Blackwells  Island  and  again  by  ambulance  or 
stretcher  to  the  City  Hospital,  as  is  now  being  done.  But 
it  is  not  a  matter  of  indifference  to  the  future  Presbyterian 
Hospital  service  that  its  new  site  is  not  in  its  present 
limited  ambulance  district  and  that  it  has  no  guarantee 
of  having  any  ambulance  service  at  all.  Of  course  the 
ambulance  supply  of  acute  disease  is  not  an  essential  to 
any  service  but  it  is  an  element  of  no  mean  importance  in 
supplying  acute  surgical  emergencies  including  fractures 
and  other  accidents.  In  the  past  the  ambulance  calls  at  the 
Presbyterian  Hospital  were  at  least  ten  a  day  and  now 
they  are  less  than  one-third  of  their  former  number.  The 
nearness  to  the  city  institutions  on  Blackwell's  Island  may 
become  an  advantage  to  the  school  if  those  institutions  can 
be  utilized  in  education  but  it  is  of  distinctly  less  value  to 
the  hospital  and  may  be  at  times  a  distinct  detriment. 

A  really  serious  objection  to  this  site  is  to  be  found  in 
the  artificial  hindrances  which  exist  to  a  free  development 
of  hospital  plans  in  a  building  restriction  that  forbids  the 
erection  of  buildings  over  60  feet  high  on  the  southerly 
border  of  the  block  and  50  feet  back  from  the  67th  Street 
building  line.  This  would  prohibit  the  adoption  of  the 
hospital  plan  which  has  been  suggested  above  as  the  ideal 
one  for  New  York  City,  or  at  least  would  limit  the  number 
of  ward  units  which  could  be  superposed  in  such  a  plan. 
When  this  land  was  purchased  for  the  new  Presbyterian 
Hospital  this  restriction  was  probably  belittled  as  of  no 

22 


consequence  by  the  Presbyterian  Hospital  authorities,  be- 
cause the  general  plan  of  the  present  Presbyterian  Hospital 
permits  of  such  a  restriction  without  detriment.  But  the 
building  plan  of  the  present  hospital  is  not  only  not  the 
best  but  is  even  one  of  the  least  desirable  plans,  and  this 
restriction  to  height  of  buildings  is  really  a  serious  block 
to  a  proper  building  plan.  In  spite  of  this  restriction  the 
proposed  site  is  perhaps  a  possibility  for  an  old-style  New- 
York  City  hospital  with  only  loose  connections  with  scien- 
tific and  educational  institutions,  but  when  considered  as  a 
site  for  a  combined  hospital  and  medical  school  the  objec- 
tions increase  in  number  although  they  may  be  surmount- 
able. One  of  the  prominent  defects  from  this  point  of  view 
is  the  existence  on  the  block  just  north  of  the  hospital  site 
of  a  large  modern  brewery.  This  will  prevent  the  com- 
bination of  a  hospital  to  the  south  and  a  medical  school 
to  the  north,  which  was  developed  in  the  foregoing  pages 
as  the  ideal  grouping  for  such  a  combination.  At  least  it 
will  prevent  it  except  at  an  expenditure  far  out  of  propor- 
tion to  the  value  of  the  property  to  be  secured.  If  the 
brewery  were  purchased  it  would  mean  its  total  demolition, 
for  none  of  it  would  be  serviceable  as  part  of  a  group  of 
buildings  either  for  school  or  hospital.  When  this  site  was 
bought  for  the  hospital  the  brewery  was  possibly  con- 
sidered as  negligible,  for  at  that  time  the  alliance  with 
Columbia  had  not  been  even  thought  of.  A  solution  other 
than  the  ideal  north  and  south  relation  of  school  and  hos- 
pital must  be  adopted  if  this  East  River  site  is  to  be  used. 
Land  can  probably  be  secured  to  the  west  of  the  hospital 
on  the  opposite  side  of  Avenue  A  for  the  building  of  the 
school.  This  land,  even  with  the  necessity  of  tearing 
down  certain  buildings,  will  be  far  cheaper  than  will  be  the 
purchase  of  the  brewery  just  referred  to.  Although  such  an 
east  and  west  location  will  be  inferior  to  the  north  and 
south  plan  it  remains  to  be  decided  whether  it  is  better 
to  adopt  the  east  and  west  site  rather  than  to  seek  an 
entirely  new  site,  where  the  ideal  institutions  can  be  devel- 
oped in  a  north  and  south  juxtaposition.  This  east  and 
west  relation,  even  if  not  the  best  theoretically,  would  give 

23 


a  combined  institution  far  in  advance  of  anything  now 
in  existence  in  New  York.  If  an  entirely  new  site  com- 
paratively near  the  Rockefeller  Institute  is  to  be  sought 
for,  a  consideration  of  the  crosstown  transportation  facil- 
ities at  86th  Street  and  at  59th  Street  should  be  a  prom- 
inent factor  in  the  choice. 

If  the  question  of  the  Sixty-seventh  Street  and  East 
River  site  is  open  for  discussion  the  subject  would  not  be 
complete  without  some  consideration  of  the  plans  of  Co- 
lumbia University  which  were  formulated  prior  to  the 
drawing-up  of  the  alliance  between  the  university  and  the 
Presbyterian  Hospital  and  which  proposed  to  move  the 
College  of  Physicians  and  Surgeons  to  the  neighborhood 
of  the  university.  It  is  impossible  to  secure  near  Columbia 
University  a  site  which  will  include  two  city  blocks 
located  north  and  south  of  each  other  except  at  the  expense 
of  tearing  down  substantial  buildings  of  modern  construc- 
tion. The  expense  of  an  ideal  site  on  Morningside  Heights 
therefore  is  more  or  less  comparable  with  the  securing  of 
a  similar  site  at  Sixty-seventh  Street  and  East  River  and  its 
necessary  purchase  of  the  brewery  already  referred  to. 
Columbia  University  owns  considerable  vacant  land  about 
116th  Street  but  how  much  of  this  could  be  used  for  de- 
veloping a  proper  clinical  and  educational  institution  is  an 
open  question  and  can  be  settled  only  after  a  consideration 
of  all  the  university  activities  and  not  of  the  medical 
development  alone. 

In  1906  the  State  Charities  Aid  Association  published  an 
interesting  report  on  the  development  of  the  hospital  situa- 
tion in  New  York.  That  report  laid  much  stress  on  the  fact 
that  the  east  side  of  the  city  was  over-supplied  with  hos- 
pital facilities  while  the  west  side  above  Forty-second 
Street  was  sadly  lacking  in  hospital  beds.  This  conclusion 
was  based  upon  a  study  of  the  existing  hospitals  and  the 
population  of  the  various  wards  of  the  city.  The  same 
conditions  exist  to-day  as  in  1906  and  there  is  no  doubt 
but  that  Morningside  Heights  offers  a  better  site  for  a 
general  hospital  than  does  the  East  River  site  at  Sixty- 
seventh  Street.     It  is  more  accessible;  it  is  equally  well- 

24 


supplied  with  light  and  air;  it  is  on  higher  ground;  it  is 
less  liable  to  be  surrounded  in  the  future  by  business  nui- 
sances. An  effort  was  made  last  Spring  to  secure  from  the 
State  Charities  Aid  Association  an  opinion  a?  to  the  relative 
value  of  these  two  sites  (Morningside  Heights  and  East 
River  and  67th  Street)  as  a  location  for  the  future  clinical 
and  educational  plant  of  the  Presbyterian  Hospital-Colum- 
bia University  Alliance.  This  was  not  possible  and  the  fol- 
lowing correspondence  will  explain  itself: 


May  2nd,  1911. 
Mr.  Homer  Folks,  Secretary, 

State  Charities  Aid  Association, 

My  dear  Mr.  Folks — 

As  you  are  aware,  an  alliance  has  been  brought  about 
between  the  Presbyterian  Hospital  and  the  College  of  Phy- 
sicians and  Surgeons,  the  medical  department  of  Columbia 
University.  I  write  to  you  for  an  opinion  upon  the  selec- 
tion of  a  site  for  the  combined  medical  school  and  hospital. 
As  Dean  of  the  school  I  feel  that  it  is  absolutely  essential 
for  the  medical  school  to  leave  its  present  quarters  in  West 
Fifty-ninth  Street  and  move  to  whatever  situation  shall  be 
decided  upon  for  the  building  of  the  Presbyterian  Hospital. 
You  are  also  aware  that  the  Presbyterian  Hospital  has 
purchased  a  site  on  the  East  River  between  Sixty-seventh 
and  Sixty-eighth  Streets,  just  north  of  the  land  owned  by 
the  Rockefeller  Institute.  You  may  not  be  aware  that  Co- 
lumbia University  had  planned  to  develop  a  new  medical 
centre  with  the  College  of  Physicians  and  Surgeons  as  a 
nucleus  and  a  University  hospital  as  a  permanent  feature 
of  the  same  on  Morningside  Heights,  near  the  present  site 
of  Columbia  University.  Columbia  University  has  pur- 
chased half  of  the  block  bounded  by  Amsterdam  Avenue 
and  Morningside  Parkway,  116th  to  117th  Street,  and  de- 
sired to  secure  the  other  half  as  a  site  for  the  proposed  new 
medical  school.  The  question  arises  in  my  mind,  therefore, 
as  to  which  is  the  better  solution  of  the  problem.     Should 

25 


the  medical  school  be  built  upon  land  to  be  secured  in  the 
neighborhood  of  the  New  East  River  site  proposed  for  the 
Presbyterian  Hospital,  or  should  the  Presbyterian  Hospital 
sell  its  East  River  site  and  locate  upon  land  on  Morningside 
Heights?  I  am  aware  that  the  State  Charities  Aid  has 
studied  the  development  of  the  hospital  situation  in  New 
York  City,  and  I  therefore  write  to  you  for  an  expert  opin- 
ion as  to  the  relative  value  of  these  two  propositions.  I 
wish  you  would  give  me  your  opinion  as  to  the  advantage 
of  these  two  situations  irrespective  of  the  consideration 
of  the  advantages  to  the  school  of  being  near  the  Univer- 
sity, or  to  the  school  and  hospital  being  near  the  Rockefel- 
ler Institute.  What  I  want  to  get  at  is,  what  is  the  relative 
value  of  the  116th  Street  and  Amsterdam  Avenue,  in  spite 
of  its  nearness  to  St.  Luke's  Hospital,  and  of  Sixty-eighth 
Street  and  the  East  River,  in  spite  of  its  nearness  to  the 
Flower  Hospital,  as  a  site  for  the  new  Presbyterian  Hos- 
pital-Columbia University  Medical  School  development. 

Very  sincerely  yours, 

(Signed)     SAMUEL  W.  LAMBERT. 


May  4th,  1911. 


Dr.  Samuel  W.  Lambert, 
New  York  City. 


Dear  Doctor  Lambert, — 

I  acknowledge  the  receipt  of  your  favor  of  the  2nd  in- 
stant, asking  for  an  expression  of  opinion  in  the  matter  of 
the  selection  of  site  for  the  combined  College  of  Physicians 
and  Surgeons  and  Presbyterian  Hospital.  The  general  sub- 
ject is  one  to  which  we  have  given  some  attention,  and  I 
should  be  glad  to  go  over  our  data  as  to  the  growth  of 
population  in  different  portions  of  the  city,  and  the  present 
hospital  provision  in  different  portions  of  the  city,  and 
report  to  you  such  suggestions  as  occur  to  us,  in  the  near 
future. 

26 


Thanking  you  for  the  opportunity  to  submit  statements 
of  such  opinions  as  we  may  arrive  at,  I  am, 
Very  sincerely  yours, 

(Signed)     HOMER  FOLKS, 

Secretary. 

June  20th,  1911. 
Dr.  Samuel  W.  Lambert, 

New  York  City. 
My  dear  Dr.  Lambert, — 

We  have  been  turning  over  in  our  minds  the  matter  re- 
ferred to  in  your  letter  of  the  second  of  May  relating  to  the 
location  of  the  proposed  new  medical  hospital  and  school. 
I  think  it  is  the  present  feeling  of  our  committee  that  they 
would  hesitate  to  offer  their  advice  upon  this  question  un- 
less they  were  officially  asked  to  do  so  by  the  trustees  of 
the  institution.  If  the  trustees  were  to  ask  our  opinion,  we 
could  then  offer  it  without  seeming  in  the  slightest  to  be 
intruding  our  opinion. 

Very  truly  yours, 

(Signed)     HOMER  FOLKS, 

Secretary. 

It  is  to  be  regretted  that  the  advantage  to  be  secured 
from  a  study  of  the  valuable  statistics  in  the  hands  of  the 
State  Charities  Aid  Association  cannot  be  applied  to  this 
question  at  the  present  time.  It  may  be  possible  to  secure 
this  aid  in  the  future,  if  asked  for  by  some  authority  com- 
bining the  interests  of  the  Hospital  and  the  University. 

The  final  selection  of  a  site  must  be  decided  on  the  fol- 
lowing general  principles: 

(1)  That  the  hospital  and  the  school  must  be  in  close 
juxtaposition  one  to  the  other.  (2)  That  the  site  fulfils  the 
general  requirements  for  a  hospital.  (3)  That  sufficient 
land  is  secured  to  enable  the  preparing  of  final  plans  for 
building  both  the  hospital  and  the  medical  school.  (4) 
That  there  will  be  a  probability  of  securing  further  land,  and 
thus  insuring  future  development  at  a  reasonable  cost. 

In  formulating  these  four  cardinal  principles  no  account 

27 


is  taken  of  association  with  other  allied  scientific  institu- 
tions and  the  adjacency  of  the  combined  hospital  and  medi- 
cal school  either  to  the  rest  of  the  University  or  to  the 
Rockefeller  Institute  is  distinctly  of  infinitely  less  import- 
ance than  is  the  question  of  the  mutual  propinquity  of  the 
hospital  and  the  school  to  each  other. 

The  ruling  influence  in  the  decision  must  be  the  ques- 
tion of  land,  and  in  considering  all  the  points  both  for  and 
against  these  various  sites  the  conclusion  seems  forced 
upon  any  impartial  observer  that  the  site  on  Momingside 
Heights  does  not  offer  a  proper  chance  for  the  future  de- 
velopment of  the  medical  centre  of  the  University  because 
the  cost  of  land  alone  will  be  prohibitive.  The  further  con- 
clusion is  equally  forced  to  the  front  that  the  Sixty-seventh 
Street  and  East  River  site  is  far  from  meeting  the  ideal  con- 
ditions which  both  the  University  and  the  Presbyterian 
Hospital  are  striving  to  attain.  Where  the  ideal  site  is  to 
be  found  is  a  subject  for  mutual  conference  and  agreement 
between  the  authorities  of  the  Hospital  and  those  of  the 
University.  In  order  to  facilitate  such  a  conference  the 
following  presentation  of  the  ideal  conditions  to  be  sought 
for  have  been  formulated: 

Completed  Institution  of  the  Alliance. — The  conditions 
presented  here  for  a  final  solution  of  this  problem  are 
probably  not  complete,  but  it  is  hoped  they  will  serve  as  a 
beginning  and  will  excite  further  discussion  of  the  many 
points  at  issue.  The  final  end  to  be  secured,  if  possible,  is  to 
develop  a  combined  hospital,  educational  and  scientific  medi- 
cal centre  in  which  all  the  specialties  of  medical  practice 
shall  have  opportunity  and  room  in  which  to  develop. 

The  Presbyterian  Hospital  has  at  present  and  probably 
would  have  expected  to  duplicate  in  its  new  buildings  in 
case  no  alliance  with  Columbia  University  had  been  per- 
fected, the  following  departments: 

1.  A  general  medical  service. 

2.  A  general  surgical  service. 

3.  A  children's  service,  which  is  mostly  for  children 
over  two  years  of  age. 

^8 


4.  A  dispensary  service  for  out-patients,  which  in- 
cludes a  partial  list  of  the  specialties  of  medicine,  at  present 
there  are  classes  in  children,  in  nervous  diseases,  in  eye,  in 
throat,  in  skin,  in  genito-urinary  diseases  and  in  gynaec- 
ology. 

6.  A  pathological  department,  including  bacteriology 
and  chemistry. 

6.    A  Roentgen  ray  department. 

The  Columbia  University  in  addition  to  its  other  school 
facilities  now  supports  the  following  departments  and  foun- 
dations, which  are  more  or  less  fully  devoted  to  clinical 
purposes : 

1.  Complete  laboratory  plants  for  pathology,  clinical 
pathology,  bacteriology,  biological  chemistry  and  pharma- 
cology. 

2.  The  Sloane  Hospital  for  Women. 

3.  The  Vanderbilt  Clinic,  which  is  an  out-patient  service 
containing  classes  in  all  the  specialties  of  medicine.  It  has 
extensive  laboratories  for  diagnosis  and  special  therapeutic 
plants  for  mechanotherapy  and  hydrotherapy. 

The  terms  of  the  alliance  between  the  two  institutions 
provide  that  the  Presbyterian  Hospital  Trustees  maintain 
a  hospital  and  the  Columbia  Trustees  maintain  a  medical 
school  and  support  the  educational  and  scientific  work  of 
the  hospital.  On  this  basis  of  mutual  support  the  hospital 
will  give  up  its  pathological  and  its  X-ray  departments  and 
delegate  this  work  to  the  University.  In  order  that  this 
combination  of  interests  may  be  properly  carried  on,  the 
two  institutions  must  build  new  plants  in  close  physical 
contact  and  on  the  best  lines  and  plans  which  the  condi- 
tions and  general  contour  of  New  York  will  permit.  Co- 
lumbia should  rebuild  the  Sloane  Hospital  as  a  part  of  the 
general  plant  and  also  a  new  Vanderbilt  Clinic  in  close  rela- 
tion both  to  the  new  Sloane  and  to  the  new  general  hospital 
of  the  Presbyterian  Hospital  corporation,  and  also  to  any 
other  new  hospitals  or  services  for  medical  specialties  which 
may  be  secured.  The  Presbyterian  Hospital  should  not 
develop  a  new  out-patient  service,  but  should  ally  itself  to 

29 


the  new  Vanderbilt  Clinic,  which  should  thus  become  the 
dispensary  of  the  hospital. 

The  new  feature  of  the  combination  of  hospital  and 
school,  which  is  suggested  above  is  the  development  of 
ward  services  for  all  the  specialties  represented  in  the  Van- 
derbilt Clinic,  which  would  automatically  become  the  out- 
patient services  of  those  ward  services.  The  addition  of 
such  ward  services  for  medical  specialties  to  a  general  hos- 
pital is  a  further  development  of  the  present  practice  of 
many  such  hospitals.  Certain  general  hospitals  have  special 
wards  for  gynaecology,  for  orthopedic  surgery  or  for  eye 
diseases.  Many  such  hospitals,  of  which  group  the  Pres- 
byterian Hospital  is  one,  have  a  special  ward  service  for 
children.  From  the  point  of  view  of  the  school  and  of  medi- 
cal education  every  specialty  should  have  its  ward  service 
and  its  dispensary  service.  If  any  of  the  existing  hospitals 
in  New  York  devoted  to  special  work  could  be  persuaded 
to  form  an  alliance  with  the  University  similar  to  the  fun- 
damental one  between  the  Presbyterian  Hospital  and  Co- 
lumbia a  great  step  in  advance  would  have  been  taken. 
Every  inducement  should  be  extended  to  such  hospitals, 
especially  to  those  which  have  antiquated  plants,  to  consider 
the  advantages  to  themselves  of  such  an  alliance.  The 
needs  of  the  various  specialties  are  perhaps  too  great  to  be 
included  in  a  general  hospital,  and  it  may  be  necessary  to 
include  special  plants  for  all  of  them.  In  any  case  the  se- 
curing of  sufficient  land  to  meet  the  possible  demands  in 
this  direction  will  do  much  to  bring  about  the  desired  end. 

In  conclusion,  this  fact  must  be  insisted  upon,  that  to 
the  future  belongs  only  the  application  of  the  general  prin- 
ciples involved  for  the  first  and  greatest  and  most  difficult 
step  has  been  taken  and  the  alliance  between  the  Presby- 
terian Hospital  and  Columbia  marks  the  beginning  of  the 
first  real  medical  centre  in  New  York.  In  the  hope  that  this 
discussion  may  further  the  interests  and  help  to  develop  the 
details  of  the  alliance,  it  is  respectfully  submitted. 

SAMUEL  W.  LAMBERT, 

Dean  of  the  College  of  Physicians 
and  Surgeons,  Columbia  University. 

30 


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